Podcast Ep 18: In-Training Exam Review (3 of 3) OB/GYN & More

Believe you can and you’re halfway there.

–Theodore Roosevelt

Welcome back to Episode 18! This is the last and final rapid review before the In-Training Exam! Remember to pause the podcast as you go through the review and quiz yourself. Let’s get started with Ob/GYN.

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OB/GYN Emergencies

• The most common cause of maternal mortality during delivery is maternal hemorrhage. Maternal hemorrhage can be caused by uterine atony, genital trauma or retained products. Uterine atony is treated with oxytocin or uterine massage. Genital trauma is treated with pressure or ligation. Retained products require removal of the products to control the hemorrhage.
• Vaginal candidiasis is treated with fluconazole or clotrimazole. Bacterial vaginosis is treated with metronidazole, twice daily for 7 days. Lastly, trichomoniasis is treated with a single dose of metronidazole.
• PID is typically caused by gonorrhea, chlamydia, or both. It is treated with ceftriaxone 250 mg IM once and doxycycline 100 mg PO BID x 14 days if the patient can tolerate PO. Cervicitis is treated with ceftriaxone 250 mg IM and azithromycin 1g PO.
• Fitz-Hugh-Curtis syndrome is a perihepatitis associated with PID. It is a difficult diagnosis to make, but suspect it in sexually active woman with right upper quadrant pain.

Pediatric Emergencies

• Suspect epiglottitis in those who were incompletely vaccinated. The first priority is airway management, which ideally involves intubation in an operating room. The second priority is antibiotics. Ampicillin-sulbactam or ceftriaxone are often used.
• Pertussis has three stages: the catarrhal stage, the paroxysmal stage, and the convalescent stage. Treatment is with a macrolide.
• There are five common congenital cyanotic heart defects, which can be remembered by the numbers 1–5. One is for Truncus Arteriosus, in which two vessels join to make one. Two is for Transposition of the Great Vessels in which the two great vessels are switched. Three is for Tricuspid Atresia. Remember three for TRIcuspid. Four is for the four defects of Tetralogy of Fallot. Lastly, five is for the five words of Total Anomalous Pulmonary Vascular Return.
• The three common acyanotic heart lesions are atrial septal defects, patent ductus arteriosus, and ventricular septal defects. Symptomatic children with such lesions typically present with congestive heart failure by 6 months of life.
• Acrocyanosis is a transient blue discoloration of the hands and feet, which can occur when a newborn is cold. Typically, the pulse oximetry reading is normal.

Procedural Emergencies

• The emergence reaction from ketamine is the most common adverse effect. The most serious adverse reaction is laryngospasm. The laryngospasm can be treated with bag valve mask ventilation. Ketamine can also be used for analgesia in lieu of opiates at a dose of 0.1–0.3 mg/kg.

Renal Emergencies

• Hematuria with hearing loss is associated with Alport syndrome. Hematuria and hemoptysis is associated with Goodpasture’s syndrome.
• Winter’s formula (pCO2 = 1.5HCO₃^– + 8 +/-2) is a formula to determine if there is appropriate respiratory compensation in a metabolic acidosis.
• MUDPILES mnemonic can be used to remember the causes of an anion gap metabolic acidosis: Methanol, Uremia, DKA, Propylene glycol, Iron or INH, Lactic acidosis, Ethylene glycol, and Salicylates.
• The HARDASS mnemonic can be used to remember the causes of a non-anion gap metabolic acidosis: Hyperalimentation, Addison’s disease, RTA, Diarrhea, Acetazolamide, Spironolactone, and Saline infusion.

Pulmonary Emergencies

• A ventilation perfusion scan (V/Q) has the highest sensitivity for excluding pulmonary embolism.
• With pulmonary embolisms, the most common finding is sinus tachycardia. Do not forget about the classic S1Q3T3 pattern.
• The common cause of SVC syndrome is malignancy. The four most common malignancies are bronchogenic carcinoma, small cell lung cancer, squamous cell lung cancer, and lymphoma.
• In drowning victims, a 4 to 6 hour observation period is typically sufficient before discharge with normal vitals and a normal exam. Any oxygen requirement or pulmonary finding on exam requires admission.
• Hypoxemia can be broken down into five categories: low inspired O₂, shunt, diffusion impairment, hypoventilation, and V-Q mismatch.
• With right to left shunt, diffusion impairment, and V-Q mismatches, the A-a gradient is increased. With hypoventilation, the A-a gradient is normal.
• The hypoxemia of right to left shunt does not improve with supplemental O2, but with diffusion impairment, hypoventilation, and V-Q mismatches it would improve.
• COPD accounts for 70% of the cases of secondary spontaneous pneumothoraces. Remember that the incidence is also three times greater in men than it is in women.
• A BNP of less than 100 essentially rules out heart failure, but an elevated BNP is not necessarily indicative of failure. Obesity can also lead to a spuriously low BNP.

Toxicological Emergencies

• Emergent dialysis is required for an acute ingestion with a lithium level greater than 4 mEq/L or for a chronic ingestion with a lithium level greater than 2.5 mEq/L. Emergent dialysis should also be initiated if there are any neurologic findings secondary to the ingestion.
• In lithium overdose, there are three classic findings: bradycardia, T wave flattening, and QT prolongation.
• Treatment for amphetamine overdoses is mostly supportive. The complex tachydysrhythmias are treated with sodium bicarbonate, agitation is treated with benzodiazepines, and hyperthermia is treated with aggressive cooling measures.
• Anticholinergic toxicity can be remembered by the mnemonic: mad as a hatter, blind as a bat, red as a beet, hot as a hare, and dry as a bone. Do not confuse the anticholinergic toxicity with the sympathomimetic toxicity as they are similar, but sympathomimetic overdoses are typically associated with diaphoresis, not dryness.
• The cholinergic toxidrome is marked by salivation, lacrimation, urination, defecation, GI upset, and emesis. Remember SLUDGE. The most deadly symptoms can be remembered by the killer b’s: bronchorrhea, bronchospasm, and bradycardia.
• A knee X-ray with hyperdense lines at the metaphysis is a classic finding in lead poisoning. Lead poisoning is treated with either succimer or IV EDTA in acute overdoses.
• Bupivacaine toxicity is treated with intralipid.
• Hydrofluoric acid is treated with calcium gluconate, either topically or intra-arterially.
• Benzodiazepine overdoses should be treated with flumazenil but use caution in those who use them chronically as reversal may precipitate seizures.
• Iron overdoses occur with ingestions of greater than 40 mg/kg. They should be treated with deferoxamine. For less significant overdoses, GI decontamination may be attempted. Charcoal is of no use here, as it does not bind Iron.
• Symptomatic colchicine overdoses must be admitted because of an elevated risk of sudden cardiac death. Other complications include renal failure, rhabdomyolysis, bone marrow suppression, and ARDS.
• The Amanita genus of mushrooms can be identified by dots or scales on their cap. They produce the deadly amatoxin.
• Amatoxin poisoning has four stages culminating in liver failure and then death. Mortality is commonly cited as 10-30%. Activated charcoal and hemoperfusion can be considered.

Traumatic Emergencies

• On bedside ultrasound, the absence of lung sliding is indicative of a pneumothorax. A-lines are horizontal lines that are the normal reflection of the pleura. B-lines are vertical “headlights” that are indicative of pulmonary edema.
• A simple pneumothorax is one involving < 10% of the hemithorax and should be treated with a non-rebreather to increase the speed of resorption. With larger pneumothoraces, a chest tube or pigtail catheter will likely be needed.
• The NEXUS mnemonic can be remembered by the mnemonic NSAID: Neurologic deficit, Spinal tenderness, Altered mental status, Intoxication, and Distracting injury. The NEXUS and Canadian C-spine rules are tools to rule patients out from the need for imaging in trauma. They both have nearly 100% sensitivity, but very poor specificities and therefore cannot rule in injury.
• Myocardial contusions are a sequela of blunt chest trauma. The most common EKG finding is sinus tachycardia. These patients require an echocardiogram. The most common course is spontaneous resorption of resolution of the symptoms. The most serious complication is delayed rupture.

That wraps up part three, the last episode in our brief In-Training Exam review! We hope you enjoyed listening! We will be taking next week off for the ITE but will resume shortly thereafter with new episodes. If you have made it this far in our podcast, you clearly take your studying seriously, and we have no doubt you will do well on the exam!

Good luck,
Jeff and Nachi

P.S. In case you missed it, here is the rest of the review: Episode 16 and Episode 17.